Liberalising trade in health services: constraints and prospects for South Asian countries

This paper attempts to examine the prospects and challenges associated with liberalising trade in health services in five South Asian countries, namely Bangladesh, India, Nepal, Pakistan and Sri Lanka. Country‐specific secondary information, a brief literature review of empirical studies and debriefing sessions with key stakeholders are employed to explore the issues related to liberalising health services trade. The health sectors in India, Nepal and Pakistan are scheduled under General Agreement on Trade in Services (GATS) classification, whereas those in Bangladesh and Sri Lanka are not. In Bangladesh, there is opportunity for investment in joint venture hospitals under Mode 3. Nonetheless, India is the largest trader in health services under all four modes. In Sri Lanka, cross‐border trade in healthcare services is found to be insignificant. Moreover, expertise in eye treatment in Nepal could also attract foreign investment in medical services under Mode 3. In contrast, Pakistan exhibits no potential under Mode 4, because of a lack of healthcare professionals. In this view, the prospects of trade in health services within the South Asian region under the four GATS modes are constrained by infrastructural, regulatory, perception‐related, logistical and cultural problems. Considering the level of development and commercial opportunities, regional integration in the health sector could be explored in such areas as telemedicine, medical tourism, cross‐border investment and capacity building of health personnel. These developments call for stronger and pro‐active government‐to‐government collaboration in the South Asian Association of Regional Cooperation (SAARC) region in a transparent and accountable manner. Copyright © 2013 John Wiley & Sons, Ltd.     

Calculation of population attributable risk for bidi smoking and oral cancer in south Asia

BACKGROUND: Bidi smoking, which is widely prevalent in India and in other south Asian countries, increases the risk of oral cancer as observed in case-control studies and metaanalysis. However, population attributable risk percent (PAR%) has not been determined yet. MATERIALS AND METHODS: Twelve case-control studies conducted in India, Pakistan, and Sri Lanka, which included information on bidi smoking and oral cancer, were analyzed countrywise to estimate PAR%. RESULTS: The cumulative cases and controls were 4778 and 6271, respectively, based on 10 case-control studies conducted in India. Among the cases, 49.1% were bidi smokers and 7.7% cigarette smokers, while they were 19.9% and 10.3%, respectively, among controls. Pooled odds ratio (OR) of bidi smoking for oral cancer was 3.3 [95% confidence interval (CI), 3.0-3.6] and 2.6 (95% CI 1.8-3.8), respectively, based on fixed- and random-effects model. Cigarette smoking, on the other hand, did not show any significant association. PAR% of bidi smoking for oral cancer ranged from 4.7% to 51.6% on individual study basis, while they were 31.4% and 24.1%, respectively, based on OR derived from fixed- and random-effects models. PAR% was 5.8% and 8.7% based on single study estimate from Pakistan and Sri Lanka, respectively. CONCLUSIONS: Bidi smoking is considered to account for a sizeable number of oral cancers in south Asian countries, which implies that cessation programs should be formulated and implemented vigorously.     

Zinc Status in South Asian Populations—An Update

This article attempts to highlight the prevalence of zinc deficiency and its health and economic consequences in South Asian developing countries and to shed light on possible approaches to combating zinc deficiency. A computer-based search was performed on PubMed, Google, and ScienceDirect.com to retrieve relevant scientific literature published between 2000 and 2012. The search yielded 194 articles, of which 71 were culled. Studies were further screened on the basis of population groups, age and sex, pregnancy, and lactation. The most relevant articles were included in the review. Cutoffs for serum zinc concentration defined for zinc deficiency were 65 µg/dL for males and females aged <10 years, 66 µg/dL for non-pregnant females, and 70 µg/dL for males aged ≥10 years. Population segments from rural and urban areas of South Asian developing countries were included in the analysis. They comprised pregnant and lactating women, preschool and school children. The analysis reveals that zinc deficiency is high among children, pregnant and lactating women in India, Pakistan, Bangladesh, Sri Lanka, and Nepal. Diarrhoea has been established as a leading cause to intensify zinc deficiency in Bangladesh. Little has been done in Sri Lanka and Nepal to estimate the prevalence of zinc deficiency precisely. A substantial population segment of the South Asian developing countries is predisposed to zinc deficiency which is further provoked by increased requirements for zinc under certain physiological conditions. Supplementation, fortification, and dietary diversification are the most viable strategies to enhancing zinc status among various population groups.Key words: Growth, Infection, Malnutrition, Zinc, South Asia     

From conflict to collaboration, local political climate accelerates ITREOH's regionalization in South Asia

As Pakistan becomes industrialized, the development of human resources is essential to addressing emerging health problems. The Fogarty International Center (FIC)-funded University of Alabama at Birmingham (UAB)-Aga Khan University (AKU) ITREOH initiative has been instrumental in filling the gaps in environmental and occupational health (EOH) training and research. Because of travel impediments to Pakistan, a regional short-term training program was implemented in Nepal and Sri Lanka. Workshop participants were from Pakistan, Nepal, Sri Lanka, India, and Bangladesh. The training programs enhanced north-to-south and south-to-south collaboration in research and training in South Asia. A major impact is the development of a certificate program in EOH at AKU. Research initiatives of regional and/or global concern are also under way in the other participating countries. The combination of face-to-face training with Web-based interaction for follow-up was optimal for short-term training.     

Population movement and malaria persistence in Rameswaram Island

The role of population movement on the persistent transmission of malaria in Rameswaram Island was studied. Majority of the inhabitants of the island are fishermen, who engage in perennial fishing. They move from one coastal place to the other for fishing and stay in temporary camps depending on season and fish availability. Such seasonal fishing camps attract fishermen from the mainland coastal villages also. The parasitological and entomological studies carried out in these places reveal that some of the camps are highly vulnerable to the movement of individuals with malaria infection and highly receptive. Rameswaram being a holy place, receives pilgrims from all over India and Nepal. Plasmodium falciparum cases recorded from the pilgrims of North India indicate the danger of the possible introduction of chloroquine-resistant parasite in the island. Also, a large number of passengers in transit from various countries, many of which are at risk of malaria transmission, stay in the island before or after visiting Sri Lanka. Such population movements being a continuous and regular feature are significant and result in failures in the operational programmes.     

Multilocus microsatellite typing (MLMT) reveals genetic homogeneity of Leishmania donovani strains in the Indian subcontinent

In this population genetic study of Leishmania donovani parasites in the Indian subcontinent, 132 isolates obtained from patients in Bangladesh, India, Nepal and Sri Lanka suffering from Kala-azar (100), post-Kala-azar dermal leishmaniasis (PKDL) (25) and cutaneous leishmaniasis (CL) (2), and from 5 patients whose clinical patterns were not defined, were analysed by using 15 hyper-variable microsatellite loci. Multilocus microsatellite typing (MLMT) data were analysed by using a Bayesian model-based clustering algorithm and constructing phylogenic tree based on genetic distances. In total, 125 strains from Bangladesh, Bihar (India) and Nepal formed a very homogeneous population regardless of geographical origin, clinical manifestation, and whether they presented in vitro or in vivo susceptibility to antimonial drugs. Identical multilocus microsatellite profiles were found for 108 strains, other strains differed in only one marker. Considerably different microsatellite profiles were identified for three Indian strains most closely related to L. donovani from Kenya, and for four strains from Indian and Sri Lankan CL cases. The circulation of a single homogeneous population of L. donovani in Bihar (India), Bangladesh and Nepal is, most probably, related to the epidemic spread of visceral leishmaniasis in this area.     

Snake venoms in science and clinical medicine. 1. Russell's viper: biology, venom and treatment of bites

Russell's viper, Vipera russelli (Shaw), is distributed erratically in 10 south Asian countries and is a leading cause of fatal snake bite in Pakistan, India, Bangladesh, Sri Lanka, Burma and Thailand. In Burma it has been the 5th most important cause of death. Its venom is of great interest to laboratory scientists and clinicians. The precoagulant activity of the venom was used by Macfarlane and others to elucidate the human clotting cascade. Up to 70% of the protein content is phospholipase A2, present in the form of at least 7 isoenzymes. Possible clinical effects of the enzyme include haemolysis, rhabdomyolysis, pre-synaptic neurotoxicity, vasodilatation and shock, release of endogenous autacoids and interaction with monoamine receptors. Russell's viper bite is an occupational hazard of rice farmers throughout its geographical range. Defibrination, spontaneous haemorrhage, shock and renal failure develop with frightening rapidity. In several countries, Russell's viper bite is the commonest cause of acute renal failure. There is a fascinating geographical variation in the clinical manifestations, doubtless reflecting differences in venom composition. Conjunctival oedema is unique to Burma, acute pituitary infarction to Burma and south India, and rhabdomyolysis and neurotoxicity to Sri Lanka and south India. Treatment with potent specific antivenom rapidly controls bleeding and clotting disorders, but may not reverse nephrotoxicity and shock. Causes of death include shock, pituitary and intracranial haemorrhage, massive gastrointestinal haemorrhage and acute tubular necrosis or bilateral renal cortical necrosis. The paddy farmer and the Russell's viper coexist in fragile symbiosis. The snake controls rodent pests but inevitably interacts with man, often with mutually disastrous results.     

Geographic origin of Explanatum explanatum (Creplin, 1847) Fukui, 1929 detected from domestic water buffaloes in Sri Lanka

The adult stage of Explanatum explanatum has economic importance in the production of ruminants, especially water buffaloes. This species has been widely reported in the Indian sub-continent. Recently, molecular analyses to reveal the dispersal route of this species were performed in Bangladesh, Nepal, and India. In the present study, we focused on E. explanatum distributed in Sri Lanka. A total of 52 flukes were collected from water buffaloes in Sri Lanka and identified as E. explanatum based on the internal transcribed spacer 2 (ITS2) region of nuclear ribosomal DNA. Analysis of the mitochondrial NADH dehydrogenase subunit 1 (nad1) gene from DNA samples detected 18 haplotypes, and five of them were identical to those from the Indian E. explanatum. The pairwise fixation index value indicated that the Sri Lankan population had a comparatively closer relationship with the Indian population than with the Bangladeshi or Nepalese populations. The Sri Lankan population showed significantly lower genetic variability than the Indian population, suggesting that the Indian population was the ancestor of the Sri Lankan population. The movement of host ruminants, including water buffaloes, was probably involved in the introduction of the fluke into Sri Lanka. The results of our study provide useful information for elucidating the geographic origin of E. explanatum distributed in the Indian subcontinent.     

The classification of tea according to region of origin using pattern recognition techniques and trace metal data

Trace metals in tea originating from various Asian and African countries were determined by using inductively coupled plasma-atomic emission spectrometry and inductively coupled plasma-mass spectrometry. Pattern recognition techniques were then used to classify the tea according to its geographical origin. Principal component analysis (PCA) and cluster analysis (CA), as exploratory techniques, and linear discriminant analysis (LDA) and soft independent modelling of class analogy (SIMCA), were used as classification procedures. In total, 17 elements (Al, Ba, Ca, Cd, Co, Cr, Cu, Cs, Mg, Mn, Ni, Pb, Rb, Sr, Ti, V, Zn) were determined in a range of 85 tea samples (36 samples from Asian countries, 18 samples from African countries, 24 commercial blends and seven samples of unknown origin). Natural groupings of the samples (Asian and African teas) were observed using PCA and CA (squared Euclidean distance between objects and Ward's method as clustering procedure). The application of LDA gave correct assignation percentages of 100.0% and 94.4% for the African and Asian teas, respectively, at a significance level of 5%. SIMCA offered percentages of 100.0% and 91.7% for African and Asian groups, respectively, at the same significance level. LDA, also at a significance level of 5%, allowed a 100% of correct case identification for the three classes China, India and Sri Lanka. However, a satisfactory classification using SIMCA was only obtained for the Chinese teas (100% of cases correctly classified), while teas from India and Sri Lanka appear to form the same class.     

Catastrophic payments for health care in Asia

Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments.     

Food Composition Activities in Developing Countries: SAARCFOODS Perspective

South Asian Association for Regional Cooperation (SAARC) comprising seven countries of South Asia, namely Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka, came into existence on December 8, 1985, when the Heads of Governments of the seven countries signed a charter for the promotion of peace, stability, amity and progress in the region. SAARC is one of the most populous regions of the world with a population of over 1.2 billion. The region is characterized by vast size, overpopulation (over 1.2 billion), diversified agroclimatic conditions with a variety of foods and food ingredients grown, multiethnicity, diversified socio- economic development and lifestyle. Despite growing various kinds of foods, the region is vulnerable to malnutrition affecting infants, children, pregnant and lactating women. The availability of reliable food composition data for the region is essential to address the problems of malnutrition which have the highest rate of prevalence in the region when compared to the rest of the world. SAARCFOODS was established in 1996 as a regional centre of INFOODS to cater for the regional needs relating to the generation and exchange of food composition data at the regional and global levels. SAARCFOODS has held two meetings in Pakistan and Nepal and identified needed activities for the region. Several committees/working groups have been constituted to deal with issues of data generation, compilation and dissemination. With the exception of Bhutan and Maldives, all member countries have their own food composition tables. All of these are incomplete with respect to the number of foods and the number of nutrients analysed. The methodology used is obsolete and most laboratories capable of food analysis are handicapped by the non-availability of sophisticated equipment and consumables, expert analysts, appropriate methodology, required funding and well-defined food composition programmes. There is a lack of quality control and quality assurance activity. A defective and limited food control programme exists only in the urban areas where only 20–30% of the population reside. This paper reviews the status of food composition data at the national, regional and global levels.     

Health promotion in South East Asia

The countries of the South East Asia region, which includes Bangladesh, Bhutan, Pakistan, Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand, have undertaken a variety of strategies to address the health challenges in the region. The ever-growing pressure of population in the region has allowed rapid transmission of communicable diseases like malaria, tuberculosis (TB), leprosy, and HIV/AIDS. One of the innovative community-based health initiatives in response to this problem is Indonesia's Primary Health Care Project. This project aimed to develop a sustainable health infrastructure by training medical staff, coordinators, village cadres, midwives and those working for TB programs; provision of ongoing guidance and education in this area; and provision of medicines and funds. The project has pioneered a process towards positive changes. Another strategy is the collaboration of youth groups, island development committees, and health workers in Maldives which has led to the declaration of two islands (Madifushi and Haa Alif Berinmadhoo) as 'no smoking' islands. In addition, Sarvodaya has successfully developed a methodology to involve Buddhist monks in AIDS prevention and control through "the Buddhist approach to AIDS prevention in Sri Lanka."     

Tobacco use: a major risk factor for non communicable diseases in South-East Asia region

Tobacco use is a serious public health problem in the South East Asia Region where use of both smoking and smokeless form of tobacco is widely prevalent. The region has almost one quarter of the global population and about one quarter of all smokers in the world. Smoking among men is high in the Region and women usually take to chewing tobacco. The prevalence across countries varies significantly with smoking among adult men ranges from 24.3% (India) to 63.1% (Indonesia) and among adult women from 0.4% (Sri Lanka) to 15% (Myanmar and Nepal). The prevalence of smokeless tobacco use among men varies from 1.3% (Thailand) to 31.8% (Myanmar), while for women it is from 4.6% (Nepal) to 27.9% (Bangladesh). About 55% of total deaths are due to Non communicable diseases (NCDs) with 53.4% among females with highest in Maldives (79.4%) and low in Timor-Leste (34.4%). Premature mortality due to NCDs in young age is high in the region with 60.7% deaths in Timor Leste and 60.6% deaths in Bangladesh occurring below the age of 70 years. Age standardized death rate per 100,000 populations due to NCDs ranges from 793 (Bhutan) and 612 (Maldives) among males and 654 (Bhutan) and 461 (Sri Lanka) among females respectively. Out of 5.1 millions tobacco attributable deaths in the world, more than 1 million are in South East Asia Region (SEAR) countries. Reducing tobacco use is one of the best buys along with harmful use of alcohol, salt reduction and promotion of physical activity for preventing NCDs. Integrating tobacco control with broader population services in the health system framework is crucial to achieve control of NCDs and sustain development in SEAR countries.     

Prevalence of chronic obstructive pulmonary disease and chronic bronchitis in eight countries: a systematic review and meta-analysis

ObjectiveTo estimate the prevalence of chronic obstructive pulmonary disease (COPD) and chronic bronchitis in eight countries in South Asia through a systematic review and meta-analysis.MethodsWe searched MEDLINE® Complete, Web of Science, Embase®, Scopus, CINAHL and reference lists of screened studies for research on the prevalence of COPD and chronic bronchitis in South Asian countries published between January 1990 and February 2021. We used standardized diagnostic criteria for definitions of COPD and chronic bronchitis. Two reviewers undertook study screening, full-text review, quality appraisal and data extraction.FindingsOf 1529 studies retrieved, 43 met the inclusion criteria: 32 provided data from India; four from Bangladesh; three from Nepal; two from Pakistan; and two from both India and Sri Lanka. Twenty-six studies used standardized diagnostic definitions and 19 were included in the meta-analysis. The estimated pooled prevalence of COPD was 11.1% (95% confidence interval, CI: 7.4–14.8%), using the Global Initiative for Chronic Obstructive Lung Disease fixed criteria and 8.0% (95% CI: 5.6–10.4%) using the lower limit of normal criteria. The prevalence of COPD was highest in north India (19.4%) and Bangladesh (13.5%) and in men. The estimated pooled prevalence of chronic bronchitis was 5.0% (95% CI: 4.1–6.0%) in India and 3.6% (95% CI: 3.1–4.0%) in Pakistan.ConclusionIncluded countries have a high prevalence of COPD although it varied by geographical area and study characteristics. Future research in South Asia should use standardized diagnostic criteria to examine the contribution of setting-specific risk factors to inform prevention and control strategies.     

The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries

OBJECTIVE: To assess the availability and affordability of medicines used to treat cardiovascular disease, diabetes, chronic respiratory disease and glaucoma and to provide palliative cancer care in six low- and middle-income countries. METHODS: A survey of the availability and price of 32 medicines was conducted in a representative sample of public and private medicine outlets in four geographically defined areas in Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka. We analysed the percentage of these medicines available, the median price versus the international reference price (expressed as the median price ratio) and affordability in terms of the number of days wages it would cost the lowest-paid government worker to purchase one month of treatment. FINDINGS: In all countries相似文献   

Conflict,forced displacement and health in Sri Lanka: a review of the research landscape

Sri Lanka has recently emerged from nearly three decades of protracted conflict, which came to an end five years ago in 2009. A number of researchers have explored the devastating effect the conflict has had on public health, and its impact on Sri Lanka’s health system - hailed as a success story in the South Asian region. Remarkably, no attempt has been made to synthesize the findings of such studies in order to build an evidence-informed research platform. This review aims to map the ‘research landscape’ on the impact of conflict on health in Sri Lanka. Findings highlight health status in select groups within affected communities and unmet needs of health systems in post-conflict regions. We contend that Sri Lanka’s post-conflict research landscape requires exploration of individual, community and health system resilience, to provide better evidence for health programs and interventions after 26 years of conflict.     

A profile of biomass stove use in Sri Lanka

A large body of evidence has confirmed that the indoor air pollution (IAP) from biomass fuel use is a major cause of premature deaths, and acute and chronic diseases. Over 78% of Sri Lankans use biomass fuel for cooking, the major source of IAP in developing countries. We conducted a review of the available literature and data sources to profile biomass fuel use in Sri Lanka. We also produced two maps (population density and biomass use; and cooking fuel sources by district) to illustrate the problem in a geographical context. The biomass use in Sri Lanka is limited to wood while coal, charcoal, and cow dung are not used. Government data sources indicate poor residents in rural areas are more likely to use biomass fuel. Respiratory diseases, which may have been caused by cooking emissions, are one of the leading causes of hospitalizations and death. The World Health Organization estimated that the number of deaths attributable to IAP in Sri Lanka in 2004 was 4300. Small scale studies have been conducted in-country in an attempt to associate biomass fuel use with cataracts, low birth weight, respiratory diseases and lung cancer. However, the IAP issue has not been broadly researched and is not prominent in Sri Lankan public health policies and programs to date. Our profile of Sri Lanka calls for further analytical studies and new innovative initiatives to inform public health policy, advocacy and program interventions to address the IAP problem of Sri Lanka.     

Progress toward poliomyelitis eradication--South East Asia Region, 1997-1998

In 1988, the World Health Assembly resolved to eradicate poliomyelitis by 2000. To achieve this goal, in 1994 World Health Organization (WHO) South East Asia Region (SEAR) member countries accelerated implementation of polio eradication strategies. In 1994, Thailand became the region's first country to initiate National Immunization Days (NIDs), followed by Bangladesh, Bhutan, India, Indonesia, and Sri Lanka (1995); Myanmar and Nepal (1996); and Democratic People's Republic (DPR) of Korea and Maldives (1997). This report summarizes the progress in achieving routine and supplemental vaccination coverage and surveillance for cases of acute flaccid paralysis (AFP) and the impact of these activities on polio eradication in the region.     

Tobacco use among South Asians: results of a community-university collaborative study

OBJECTIVE: Although South Asians (individuals from India, Pakistan, Sri Lanka, Bangladesh, Nepal, Bhutan, and the Maldives) are the third largest Asian group in the USA, relatively little data are available to document their use of tobacco. We collected data from a community sample of 344 South Asian adults to assess rates of smokeless tobacco product use and smoking and examine demographic predictors of use. DESIGN: Non-random sample; cross-sectional survey. RESULTS: Close to a third of the sample (28%) reported current use of smokeless tobacco products. In multivariate analyses, gender and ethnicity were significant predictors of use of smokeless tobacco products. Men and Bangladeshis were more likely to use smokeless tobacco. The overall rate of daily cigarette/bidi smoking observed in our sample (9%) was similar to that observed in the population of California (10%); however, the rates among men (19%) and some ethnic subgroups (16% for Pakistanis) were significantly higher. Gender, ethnicity and years in the USA emerged as significant predictors of daily smoking with men and Pakistanis being significantly more likely to smoke. Length of stay in the USA was inversely related to daily smoking. CONCLUSION: These findings emphasize the need to disaggregate data for South Asians and suggest that tobacco control interventions should target specific segments of the population (men, Bangladeshis, Pakistanis). Interventions to decrease use of smokeless tobacco products are especially warranted for South Asians.